Continuum of Care

The Department of Defense defines the Continuum of Care as Recovery, Rehabilitation, and Reintegration. The Air Force has divided those stages into seven phases that align better with an Airman’s journey through the Continuum of Care.

These seven phases also make it easier for the Airman and their caregiver to understand where they are in the process and helps the Care Management Team with trigger points to know when to introduce new members required for each phase of care.

The seven phases that are used anticipate the Airman and family and/or designated caregivers needs. Family members and caregivers play an important role in a seriously or severely ill or injured Airman’s recovery and transition. They provide emotional support and stability and assist the Airman in navigating available transition benefits and programs. The Air Force defined phases of the Continuum of Care are listed below.

IDENTIFICATION PHASE

Combat and non-combat ill or injured service members are assigned a CMT consisting of a Recovery Care Coordinator, Non-Medical Care Manager, and a Medical Case Manager. The RCC will make contact within 72 hours of assignment, conduct an initial assessment of the Airman and family’s needs within 5 duty days, and share this information with the CMT within 15 duty days. Coordination with, and notification to the Airman & Family Readiness Center, unit leadership, and Family Liaison Officer is essential to properly address needs of the Airman, their family and/or their caregiver.

RECOVERY AND TREATMENT

Airmen in this phase are hospitalized. The MCM will coordinate the efforts of the CMT members. The CMT will coordinate prioritized medical and non-medical support and services and begin development of the coordinated Interagency Comprehensive Plan. Whether the Recovering Service Member starts out in either Recovery and Treatment or Rehabilitation phase of care, the RCC will coordinate with the NMCM regarding the Airman’s personnel and financial needs based on initial and ongoing assessment. This will normally be accomplished no later than the 15th day from case initiation. NMCMs will coordinate resolution of those needs with the Air Force’s Personnel Center and Defense Finance and Accounting Service.

REHABILITATION

Airmen in this phase are in an outpatient status. When an Airman is in rehabilitative care and reaches a point where optimal medical benefit is achieved, the CMT coordinates with the Airman, family and caregiver to develop a plan of action for continuance of Air Force service or transition into the civilian community. Additionally, the CMT will continue to monitor the Airman, family, or caregiver needs; resolve issues (medical, financial, personnel, logistical); and assist with locating services and resources as needed.

FITNESS EVALUATION

Airmen in this phase are undergoing a Medical Evaluation Board/Physical Evaluation Board. The CMT will educate the Airman on full spectrum of the Integrated Disability Evaluation System and provide sound policy guidance and direction based on Airman’s goals. The RCC and NMCM actively advocates for the Airman and monitors the evaluation process, ensures personnel policies are afforded as applicable, explores career and education goals, assesses financial wellness, and assists the Airman, family and caregiver with their transition goals.

REINTEGRATION/TRANSITION

Airmen in this phase have received a decision from the PEB and are projected for separation or retirement. The NMCM coordinates to ensure the Airman is provided assistance with navigating his/her transition to the civilian community. The NMCM assesses the Airman’s needs and, with the help of the RCC, adjusts services to ensure the Airman, family, and caregiver are afforded applicable transition services. The NMCM, in coordination with the other CMT members, coordinates a hand-off to outside agencies (VA, Department of Labor, community resources).

STABILIZATION/RESOLUTION

Airmen in this phase have returned to duty, separated or retired and are reintegrating either back into their military or into the civilian community. The NMCM will continue to proactively foster resilience, independence, and stability with the Airman. Members of the CMT will coordinate with the VA Case Manager to ensure all applicable entitlements and benefits have been applied for. NMCMs, with assistance from AFPC specialists, will coordinate transitional financial assistance and troubleshoot retired pay account issues. The NMCM with the help of the RCC, as necessary, will coordinate with the VA Case Manager to ensure Airman is connected to the VA and other agencies. While it varies from case to case and is always contingent on the RSM’s needs, the goal of the NMCM is to ensure all benefits and entitlements are assured within six months after the RSM leaves military service.

SUSTAINMENT

These Airmen have successfully reintegrated, achieved stability and have been made fully aware of all applicable benefits and entitlements. A final assessment will be completed to confirm resilience, independence, and stability. AFPC/DPFW will continue to provide outreach services through events coordination, news bulletins and periodic phone contacts. WII are considered “Airman for Life” and have reach-back capability to obtain assistance with issues or concerns.

Referral

Anyone can refer an active-duty Airman into the AFW2 program; download the worksheet by clicking the button below and submit the finalized form via email.